Mayor Grant - HATT foundation❑ MAIL CHECK TO VENDOR E RETURN CHECK TO DEPTA INCLUDE BACK-UP W/ CHECK
CITY OF BOYNTON BEACH
DIRECT PAYMENT REQUISITION
Please issue a check in the amount of $200.00
TO: HATT Foundation
625 N. Flagler Drive, Suite 605
West Palm Beach, FI 33401
FOR: Communitv Investment Funds
Mayor Grant Community Investment Funds
Requested By: Queenester Nieves
Approvals:
Div Head
Finance Dept.
City Manager
VENDOR #: 17861
-!
Date: , 2020
FUND
DEPT BASIC
ELE
OBJ
AMOUNT
001
1110 511
95
47
200.00
�.i1I1___
EXHIBIT "A"
COMMUNITY SUPPORT FUNDS
REQ UES T FORM
Part I - Summary of Request (to be completed by City Clerk)
Date of Request:
Requested by Mayor/Commissioner-
Amount Requested:
Recipient/Payee:
2/27/2020
Mayor Steven B. Grant
$ 200.00
HATT Foundation
Description of project, program, or activity to be funded: Funding will be used for the
HATT 2020 Project Feed -A -Family event on April 4, 2020, helping to end hunger in our
local communities. The goal is to raise funds to distribute to 5,000 needy families and
at -risk children a 5 -gallon bucket filled with food. For every $35 donated, a 5 -gallon
bucket of food will be distributed to a needy family of 4 or 5 members.
R15-055
Part II - Availability of funds
The annual appropriation of funds available to the requesting Member of the
Commission listed above is $ 2,000.00
The balance of funds available for the requesting Member of the Commission is
$ 400.00
Accordingly:
Rr' There are funds available as requested
❑ There are insufficient funds available as requested
Dated: By: �� .� .
City Clerk
Part III -Eligibility Evaluation
L -V Public funds will not be used to improve private property unless there is a clear
public need, purpose and benefit
Lt' The recipient/payee provides services within the City
!The public purpose is beneficial to the entire community serve by such donation
Dated:3 � B
Y
Requesting Member o the City Commission
.•
Farm W'9 Request for Taxpayer
(Rea. December 20 14)
Department of the TreawIdentification Number and Certification
ry
Internal Reve^.ue Sauce
las shown on your income tax retu
Adams Animal Rescue Lf
rss nare/d:sreoarded eat.ty name.
ie :s required on th s tine: do not it
of the Palm Beaches, Inc
Give Form to the
requester. Do not
send to the IRS.
13 Check apo opnate box for federal tax Classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to
certa n entities, not mdividuats; see
CJ Indmduat/sole proprietor or C Corporat on ] S Corporation El Partnership ❑ TrusI/ at instructions on page 3):
single -member LLC Exempt payee code (if any)
O Limited l ability company. Enter the tax classification (C=C corporation. S=S corporation. P=partnership) ►
Note. Fa a singe -member LLC that is d sregarded, do not check LLC; check the appropriate box m the line above for Exemotion from FATCA repo ting
the tax classihcaton of the single -member owner. code (if any)
Other (see instruct ons) ► Non-profit Ufit'- ro n^ca m+ kt d.: is M r.+. US)
5 Address (number, street, and apt. or suite no.) Requester's name and address (coffona')
3100-3200 N Military Trail
6 Cay, state, and ZIP code
West Palm Beach, FL 33409
7 list account number(s) here (optional)
Fetter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid j Social security number
backup withholding. For individuals, this is generally your social security number (SSM. However, }ora -
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other W
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3. or
Note. If the account Is in more than one name, see the instructions for line 1 and the chart on page 4 for I Employer Identification number I
guidelines on whose number to enter.
5 9- 0 6 3 7
5 18T,
T11
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and >
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt. contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3. , r �
i01911 Signature of J_'�
Here I U.S. person to- J/ `F O Y�J Data ► ?0/7
General Instructions
Section references a e to the Internal Revenue a unl s otherwise noted.
Future developments. Information abo!004rng affecttrg Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov1fiv9.
Purpose of Form
An indredual or entity (Form W-9 requester) who is required to fife an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSM, individual taxpayer identification
number (111M. adoption taxpayer identification number (ATIN). or employer
identificatlon number (EIN), to report on an information return the amount pa•d to
you. or other amount reportable on an information return. Examples of information
returns inaude, but are not limited to. the following:
• Form 1099 -INT hriterest earned of paid)
• Form 1099 -DIV (dividends. including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by
brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (mercnam card and th rd party network transactionS)
• Form 1098 [home mortgage intprest). 1098-E (student loan interest), 1098-T
(tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acgws von or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN.
N you do not mium Form W-9 to the requester with a 77N, you might be Subject
to backup withholding. See What is backup withholding? on page 2.
By s-gn nq the fi'!ed-out form, you:
1. Cert4y that the TIN you are giving is correct (or you are wa,t!ng for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exerpitan from backup withholding if you are a U.S. exempt payee. tf
app!icab'e, you are also certifying that as a U.S_ person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected income. and
4. Certify that FATCA code(s) entered on th-s form Of any) ind.cating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
Cnt. No. 10231X Form W-9 (Rev. 12-2014)